Neurology Headache Questionnaire

1 Neurology Headache QuestionnairePatient s Name: Date: 1. Did the headaches start after an accident, illness or infection?2. How long has the patient had these headaches?3. Are the headaches constant or do they come and go?4. How often do the headaches occur? (daily, weekly, monthly)5. Do the headaches occur at a certain time of the day? _____morning _____afternoon _____night6. Are the headaches becoming stronger, lasting longer or occurring more frequently?7. Do the headaches ever wake up the patient up when he is sleeping?8. Does rest or sleep relieve the Headache ?

2 9. Do the headaches stop the patient from doing things? (like playing, watching TV, going outside or doing homework.)10. Has the patient ever missed school or work because of a Headache ?11. Is the Headache pain intense when it starts, or does it start out small and builds up?12. Please check all of the things that bring on the headaches:_____Odors (Perfume, cigarettes)_____Fatigue_____School_____H unger (missing meals)_____Loud noises_____Anxiety or stress_____Exercise or playing_____Ice Cream_____Family problems_____Too much sleep (sleeping in)_____Bright Lights_____Menstrual cycles_____Too little sleep (staying up late)_____Sunshine_____Birth Control Pills_____Riding in a car_____Hot weather_____Alcohol (wine, beer)_____Medications Which ones?

3 _____Certain foodsWhich ones? (for example: chocolate, peanut butter, eggs, milk, pizza, etc.)13. Are nasal congestion, sinusitis or allergies associated with the Headache ?14. Are there any warning signs BEFORE the Headache begins?_____Paleness_____Mood swings (either high or low)_____Irritability_____Dizziness_____ Tired, sleepy, or yawning_____Increased appetite_____Rings around the eyes_____Hyperactivity_____Craving sweets_____Eye problems (like blurred vision, black spots, flashing lights, or double vision) If there are any other warning signs, please describe Where is the Headache located?

4 _____Left side_____Forehead_____All around the head_____Right side_____Temples_____Top of the head_____Neck_____Back of the headIf the pain is another part of the head please describe or mark the location:16. What does the pain feel like?_____Throbbing or pounding (like a hammer)_____Exploding_____Sharp_____Tigh tness (like a rubber band wrapped around the head)_____Dull_____Aching_____PressurePl ease describe the pain in your own words:17. Are there any other symptoms when the patient has a Headache ?_____Nausea_____Stomach pains_____Weakness in the arms or legs_____Vomiting_____Confusion_____ Numbness in the arms or legs If there are any other symptoms, please describe them:18.

5 Who else in the family has had headaches, migraines, sick headaches, motion sickness, brain freeze from eating ice cream or had trouble taking Birth Control Pills because of headaches? 19. Describe any stresses in the last year (such as separation, divorce, job changes, moves, death in the family, or poor grades).20. Who has treated the patient for headaches? When were they treated?What tests were done?_____CT scan_____Eye Exam_____Sinus X-rays_____MRI_____Dental exam_____Allergy Tests_____Spinal Tap_____Allergy tests____Blood tests etc.)Any other tests?: 21. What medications or treatments have you tried? (glasses, allergy shots, chiropractor, herbal medicines, Motrin, Tylenol, prescription medicines, etc.

6 23. What questions do you have about the patient s headaches? What worries you the most? What medical tests, medicines or therapies do you what to know about? DayHow longSeverityWhereDescriptionTriggersTrea tmentDate & Timedid it last?*(1->10)is it? see below **see below Sunday 6/27 6:30pm 3 hours 5 + pounding light sensitive vomited hot weather skipped lunchMotrin, rest, ice15. Where is the Headache located?_____Left side_____Forehead_____All around the head_____Right side_____Temples_____Top of the head_____Neck_____Back of the headIf the pain is another part of the head please describe or mark the location:16.

7 What does the pain feel like?_____Throbbing or pounding (like a hammer)_____Exploding_____Sharp_____Tigh tness (like a rubber band wrapped around the head)_____Dull_____Aching_____PressurePl ease describe the pain in your own words:17. Are there any other symptoms when the patient has a Headache ?_____Nausea_____Stomach pains_____Weakness in the arms or legs_____Vomiting_____Confusion_____ Numbness in the arms or legs If there are any other symptoms, please describe them:18. Who else in the family has had headaches, migraines, sick headaches, motion sickness, brain freeze from eating ice cream or had trouble taking Birth Control Pills because of headaches?

8 19. Describe any stresses in the last year (such as separation, divorce, job changes, moves, death in the family, or poor grades).20. Who has treated the patient for headaches? When were they treated?What tests were done?_____CT scan_____Eye Exam_____Sinus X-rays_____MRI_____Dental exam_____Allergy Tests_____Spinal Tap_____Allergy tests____Blood tests etc.)Any other tests?: 21. What medications or treatments have you tried? (glasses, allergy shots, chiropractor, herbal medicines, Motrin, Tylenol, prescription medicines, etc.)23. What questions do you have about the patient s headaches? What worries you the most? What medical tests, medicines or therapies do you what to know about?

9 DayHow longSeverityWhereDescriptionTriggersTrea tmentDate & Timedid it last?*(1->10)is it? see below **see below Sunday 6/27 6:30pm 3 hours 5 + pounding light sensitive vomited hot weather skipped lunchMotrin, rest, iceNeurology Headache Diary(please copy this form as often as you need to)7645 Wolf River Circle Germantown, TN 38138(901) 572-3081 Fax: (901) : Chart No: Current Medicine.

10 Starting Date: Current Medicine: Starting Date: * Severity: 1=very mild 3=mild 5=moderate 8=severe 10=worst Headache ever Description:pounding, aching, stabbing, nausea, vomiting, sensitive to light or sound, squeezing, explosive**Triggers:Emotions: stress, anxiety Sleep: too much, too little Environment:cigarettes, perfumes, bright lights, riding in the car Weather: hot days, cold days, windy days, rainDietary:caffeine drinks, chocolate, aged cheese (blue, chedder), hot dogs, bacon, peanuts, MSG, chinese food, artificial sweetener, ice cream, skipping meals, alcohol, red wineHormonal: menstrual cycles, birth control pills <--------------------- For Example --------------------------------------------------------------------------------------------------->